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Author's personal copy
Orthopaedics & Traumatology: Surgery & Research (2011) 97, 479—488
ORIGINAL ARTICLE
Is distal ulna resection influential on outcomes of
distal radius malunion corrective osteotomies?
B. Coulet a,∗, M. Id El Ouali a, J. Boretto b, C. Lazerges a, M. Chammas a
a
Lapeyronie Regional Academic Hospital Center, Upper Extremity and Hand Surgery Department, 371, avenue du
Doyen-Gaston-Girard, Montpellier cedex 5, France
b
Buenos Aires Italian Hospital, Orthopaedic and Hand Surgeon, Potosí 4247, C1199ACK Buenos Aires, Argentina
Accepted: 7 March 2011
KEYWORDS
Radius;
Malunion;
Distal radio-ulnar
joint;
Osteotomies
Summary
Introduction: The mechanical repercussions of distal radius malunion on the distal radio-ulnar
(DRU) joint are common and inconsistently corrected by radius osteotomy alone. Ulnar resection
has thus become a palliative solution.
Hypotheses: Does ulna resection influence the outcomes of distal radius malunion corrective
osteotomies? What preoperative factors warrant preserving the distal radio-ulnar joint?
Patients and methods: Twenty-one corrective osteotomies of the radius were retrospectively
reviewed. Ulna resection was performed in cases of cartilage damage, joint incongruence, or
persistent stiffness in pronosupination after osteotomy of the radius. After the osteotomies,
two groups were identified: 10 cases with preservation of the distal end of the ulna (DRU+) and
eleven with distal resections (DRU—).
Results: At review, all the osteotomies had united, with comparable anatomical restoration
of the radial epiphysisfor the two groups. We noted a statistically significant gain in mobility
after osteotomy for both techniques (but no difference between them) and comparable grip
strengths with 89.8% of the contralateral side for the DRU+ group versus 90.4% for the DRU—
group. Pain (scale, 0—3) had significantly diminished for both groups decreasing from 1.9 to
0.3 for the DRU+ group and from 2.5 to 1.1 for the DRU— group, with no significant difference
between them. The Mayo Clinic Wrist Score and the DASH score did not differ significantly with
73/100 and 13.5 for the DRU+ group compared with 68.2/100 and 20.2 for the DRU— group,
respectively.
Discussion: These results show that the impact of ulna resection after distal osteotomy of the
radius is limited as reflected by radiological correction, mobility and grip strength. However,
after resection pain in the ulnar tilt of the wrist due to instability of the distal ulnar stump was
noted. Besides cartilage damage, ulnar deviation of over 5 mm was, for this series, a constant
factor in non-preservation of the DRU joint.
Level of evidence: Level IV. Retrospective study.
© 2011 Elsevier Masson SAS. All rights reserved.
∗ Corresponding author. Lapeyronie Regional Academic Hospital Center, Upper Extremity and Hand Surgery Department, 371,
avenue du Doyen-Gaston-Giraud, Montpellier cedex 5, France. Tel.: +33 4 67 33 85 37; fax: +33 04 67 33 79 66.
E-mail address: [email protected] (B. Coulet).
1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2011.03.022
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480
Introduction
Distal radius malunions result from a defect or a loss of fracture reduction and result in misalignment of the radiocarpal
joint surfaces as well as the distal radio-ulnar (DRU) joint
surfaces [1,2].
Extra-articular forms lead to displacement of radiocarpal
mobility sectors and for the most severe cases, compensatory misalignment of the carpus that may set in over time
[3,4]. Disorganization of the DRU is the main source of pain
in patients with pronosupination stiffness and invalidating
pain. Other than cartilaginous lesions facing the fracture
line, misalignment of the radial side of the DRU is the major
cause of its incongruity. When necessary, osteotomy of the
radius sometimes realigns the sigmoid fossa of the radius
and thus rebalances the two bones of the forearm.
Inversely, substantial cartilaginous deformities or lesions
make preservation of the DRU impossible, requiring palliative treatment. The decision to preserve the DRU is often
made intraoperatively after realignment of the radial epiphysis.
Resection of the distal extremity of the ulna associated
with stabilization was described at the beginning of the
twentieth century by Darrach [2]. Widely used, it has been
criticized over the past 30 years, resulting in certain authors
reporting a loss of grip strength and residual pain. Nevertheless, in the context of distal radius malunion correction,
this technique has the advantage of not requiring excessive
resection of the ulna and not being dependent on new bone
union.
The objective of this study was to assess the impact of
palliative treatment compared to conservative treatment
and to specify the preoperative radiological criteria for the
immediate indication of this procedure.
Patients and methods
Inclusion criteria
Twenty-one distal metaphyseal osteotomies of the radius
performed from 2002 to 2008 for correction of extra-
B. Coulet et al.
articular malunion were studied retrospectively. The
procedure was indicated for the most part because of pronosupination limitation and pain on the ulnar side of the wrist.
The decision not to preserve the DRU joint was made
either preoperatively because of significant cartilage lesions
based on the arthro-CT or more often intraoperatively when
after correction of malunion DRU instability or pronosupination block persisted.
Patients with less than 18 months follow-up and those
who had undergone another procedure than ulnar resection
to correct DRU problems were excluded from the study.
Composition of the groups
Two groups were formed:
• DRU+ group: 10 patients who had undergone osteotomy
of the radius with preservation of the DRU joint;
• DRU— group: 11 patients whose osteotomy of the radius
was associated with resection of the distal extremity of
the ulna using the same technique.
The demographic data on the two groups is reported in
Table 1; only age at the time of the osteotomy differed
between the two populations at the limit of significance
(P = 0.07).
As for the initial lesions, the DRU+ included eight
malunions with posterior displacement, five secondary to
orthopaedic treatment, two after reduction associated with
styloid pins, and one after osteosynthesis with an anterior
plate. Two cases presented anterior displacement, one after
orthopaedic treatment and one from hypercorrection due to
intrafocal pinning. In this group, seven patients presented a
fracture of the ulnar styloid and DRU dislocation.
Treatment of the initial fracture was complicated by two
cases of neurological algodystrophy syndrome, one case of
neuroma on a sensory branch of the radial nerve, one tendon rupture, and one rupture of the extensor pollicis longus
(EPL).
In the DRU— group, six cases of malunion presented
posterior displacement despite styloid pinning and five
Figure 1 Different initial joint amplitudes (light shading) and at revision (dark shading) for both groups, with preservation of the
distal radio-ulnar joint (DRU+) (first two columns) or non-preservation (DRU—) (last two columns).
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Distal resection of the ulna and radial osteotomies for malunion
Table 1
481
Demographic data on both groups of patients.
Groups
n
Age
Sex ratio
f/m
Dominant
side
Work
injury
Heavy
workers
Delay from
fracture to
osteotomy
(months)
Follow-up
(months)
DRU+
DRU−
10
11
37.3 ± 14.4
49.8 ± 12.4
4/6
7/4
5/10
5/11
2/10
3/11
3/11
1/11
10.7 ± 7.8
12.0 ± 10.9
41.1
45.6
DRU+: preservation of distal radio-ulnar joint; DUR−: non-preservation.
presented anterior displacement, two after orthopaedic
treatment and three secondary to hypercorrection due to
intrafocal pinning. In eight cases, the DRU joint was dislocated and in five the ulnar styloid was fractured. The
initial treatment was complicated by neural algodystrophy
syndrome, two from ulnar nerve compression at the Guyon
canal and one medial nerve of the carpal canal.
There was no statistically significant difference in initial
mobility between the two groups (Fig. 1).
On the radiological level, considering anterior displacement malunions separately from posterior displacement
malunions, despite the greater deformities in the DRU—
group, no statistically significant difference was demonstrated between the two groups in terms of alignment of
the distal radial joint surface (Figs. 2 and 3). Only ulnar
deviation differed very significantly between the groups
(P = 0.002), with a value of 1.5 mm (range, 0—3 mm) in the
DRU+ group versus 10.5 mm in the DRU— group (range,
0—18 mm).
Surgical techniques
bone graft harvested either on the iliac crest or from the
resected ulnar head (DRU— group). After realignment of
the radius, the DRU joint stability and the pronosupination
aspect were assessed; in cases of instability or pronosupination stiffness, the ulnar head was resected.
Ulnar head resection technique
Through a dorsal approach to the distal radius and ulna, the
sixth compartment was opened opposite the extensor carpi
ulnaris (ECU) tendon. The longitudinal capsulotomy of the
DRU was performed at the base of the joint space, so that
a wide capsuloperiosteal flap with a medial hinge could be
detached. The ulnar head was resected after a transversal
osteotomy of the distal part of the neck. The joint capsule and the retinaculum of the extensors were carefully
closed, with the ulna in the reduced position. A retinacular
flap stabilized the ECU in the dorsal position.
No other complementary stabilization procedure on the
ulna was performed in this series.
The details of the different procedures can be found in
Table 2.
Corrective osteotomies of the radius
The same techniques were used in both groups.
The osteotomies with dorsal opening were performed
through a posterior approach to the radius. Osteosynthesis was provided by styloid pinning following a diverging
pattern. Anteriorly tilting malunions were corrected with
palmar opening osteotomy maintained by an anterior interlocking plate. The bone defect was filled with trapezoid
Evaluation method
Figure 2 Sagittal radiological analysis: Deviations in anterior
tilt (degrees) before and after correction according to the type
of anterior (right) or posterior (left) malunion for each group
with (DRU+) or without (DRU—) preservation of the distal radioulnar joint.
Figure 3 Radiological analysis on the AP images. Deviations
in medial tilt (degrees) before (light shading) and after (dark
shading) osteotomy according to the type of anterior (right) or
posterior (left) malunion for each group with (DRU+) or without
(DRU—) preservation of the distal radio-ulnar joint.
All the patients were seen at the last follow-up by a different
physician who was not among the operators.
Subjective satisfaction and the degree of pain experienced were scored according to the following criteria: (4:
very satisfied; 3: moderately satisfied; 2: dissatisfied but
able to work; 1: dissatisfied, unable to work), (0: no pain;
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482
Table 2
B. Coulet et al.
Details of surgical procedures performed in both groups depending on type of malunion.
Groups
Type of malunion
n
Surgical procedures
DRU+ [10]
Dorsal tilt deformity [8]
6
Dorsal opening wedge osteotomy stabilized with
pins + iliac crest bone graft
Dorsal opening wedge osteotomy stabilized with
pins + synthetic bone
Anterior opening wedge osteotomy stabilized with
plate + iliac crest bone graft
Anterior opening wedge osteotomy stabilized with plate
without graft
2
Dorsal tilt deformity [2]
1
1
DRU− [11]
Dorsal displacement [6]
6
Palmar tilt deformity [5]
4
1
1: slight pain during intense activities and/or pain only with
changes in weather; 2: pain during simple movements with
no limitation in activities; 3: pain with limitations in daily
activities).
Joint mobility was measured using a goniometer and grip
force with a dynamometer (JamarTM ).
The Mayo Clinic wrist score provided an overall assessment [5] (Table 3), the DASH score [6] evaluated functional
incapacity.
X-rays were used to assess radial epiphyseal misalignment; ulnar sliding was assessed with the Bouman index [7]
(Fig. 4) (a value less than 0.83 was considered pathological).
Dorsal opening wedge osteotomy stabilized with
pins + graft with ulnar head
Anterior opening wedge osteotomy stabilized with
plate + graft with ulnar head
Dorsal closing wedge osteotomy stabilized with pins
The statistical analysis was carried out with Excelstat® ,
using Wilcoxon nonparametric tests to compare paired variables and the Mann-Whitney test for ordinal variables.
Results
All the patients were seen for follow-up at a mean
43.5 months (range, 23—67 months).
Complications
In the DRU+ group there was one rupture of the EPL and
the extensor digitorum communis of the fourth metacarpal.
In the DRU— group, four patients reported painful ECU
tendinopathy. Three wrists presented ulnar sliding with a
pathological Bouman index score and two of them ossifications of the resection cavity of the ulna, but with no clinical
repercussions.
Functional results
Figure 4 Bouman ulnar translation index of the wrist [7].
AB / (AC—DC) = 0.87 ± 0.04. A: tip of radial styloid; B: medial
side of the radial joint surface; C: medial part of the lunatum
joint surface; D: lateral edge of the lunatum. A value less than
0.83 indicates pathological ulnar translation of the carpus.
Satisfaction index and overall wrist assessment
In both groups, patient satisfaction was high: with a maximum value of 4, this score was 3.5 (range, 2—4) for DRU+
and 3.6 (range, 2—4) for DRU— (NS). In the DRU+ group, 84%
returned to their former activities versus 82% in the other
group.
The Mayo Clinic Wrist Score at revision was 73.0 out of 100
in the DRU+ group (range, 65—80) and 68.2 (range, 35—85)
in the DRU— group; the difference between the two groups
was not significant (P = 0.76). In the DRU+ group, this corresponded to one good result and nine fair results, and for the
DRU— group to three good, four fair, and four poor results.
The mean DASH values were 13.5 (range, 5—28) in the
DRU+ and 20.2 (range, 5—29) in the other (NS).
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Distal resection of the ulna and radial osteotomies for malunion
Table 3
483
Mayo Clinic functional score [5] taking pain, function, mobility, and strength of the wrist, out of 100 points.
Mayo Clinic wrist score (100 points)
Score
Characteristics
Pain (25 points)
25
20
15
0
None
Low, occasional
Moderate, tolerable
Severe, intolerable
Function (25 points)
25
20
15
0
Resumed work activity
Returned to work, adapted position
Work possible but unemployed
Cannot work because of pain
Mobility (25 points)
(flexion/extension)
25
15
10
5
0
≥ 120◦
91◦ —119◦
61◦ —90◦
31◦ —60◦
≤ 30◦
Grip strength (25
points) (percentage
of contralateral side)
25
15
10
5
0
100%
75—99%
50—74%
25—49%
0—24%
Overall assessment
Excellent
Good
Moderate
Poor
90—100 points
80—89 points
65—79 points
< 65 points
Clinical results
Pain
Initially, the mean pain score was 1.9 out of a maximum
value of 3 (range, 0—3) in the DRU+ group and 2.5 (range,
0—3) in the other group. This difference was not statistically
significant (P = 0.21). This pain was exclusively on the ulnar
side of the wrist.
At revision, these values decreased significantly, dropping to 0.3 (range, 0—1) and 1.1 (range, 0—2), respectively.
The difference between the two groups at revision was statistically close to the significance threshold (P = 0.17).
In the DRU+ group, three patients complained of pain,
but only during intense activities. On the other hand, after
resection of the ulna, only three patients were strictly painfree, five presented pain only during intense activities, and
two for activities of daily life. Following a work accident,
one patient could not perform his daily activities.
Mobility
The initial wrist mobility values and those at revision are
reported in Fig. 1.
The gain in mobility in the different sectors after
osteotomy was statistically significant for both groups
except for radial inclination and in the DRU— group for flexion (P = 0.083).
Supination, which was consistently limited preoperatively, recuperated in both groups.
For all of the patients, the osteotomy did not displace the
mobility sector, but increased it statistically significantly,
rising in the DRU+ group from 89.5◦ initially (range, 70—160◦ )
to 113.8◦ at the last follow-up (range, 75—130◦ ) and in the
DRU— group from 75◦ (range, 20—115◦ ) to 112.9◦ (range,
80—140◦ ).
Digitopalmar grip strength
The absolute value of grip strength at revision was
31 kg (range, 20—44 kg) for the DRU+ group and 19.5 kg
(range, 4—38 kg) for the DRU— group. This difference
was statistically significant. Expressed as a percentage of
the contralateral score, these values were 89.8% (range,
64—138%) and 90.4% (range, 33—200%), respectively.
Radiological results
At revision, all the osteotomies had united.
The anterior and medial tilt values are reported in
Figs. 2 and 3. Anatomic restoration was identical in the
two groups for all types of malunion. Ulnar variance in the
DRU+ group decreased from 1.4 mm (range, 0—4) to 0.3 mm
(range, 1.5 to —4 mm) (NS); it was a mean 10.5 mm (range,
0—17 mm) in the DRU— group.
In Fig. 5, the cases in each group are reported according
to their anterior tilt on the X-ray along the x-axis (sagittal plane) and their ulnar deviance along the y-axis. All the
subjects are reported for the preoperative measurements
and only those in the DRU+ group at revision (those who
had a measurable ulnar deviation). A high level of consistency in the distribution of the groups was observed. The
cases whose DRU was preserved all had ulnar deviance less
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484
Figure 5 Illustration of the different cases according to their
ulnar deviation on the x-axis and their anterior tilt of the radius
on the y-axis. The open triangles correspond to the preoperative DRU+ group and the filled squares to the postoperative
DRU+ group. The open circles correspond to the preoperative
DRU— group (this group had no postoperative results). The diagram clearly shows that beyond 5 mm of ulnar deviation DRU
congruity could not be restored by radial osteotomy alone. We
also noted that the small amounts of shortening making conservative treatment possible were for the most part found in cases
of malunion with posterior displacement.
than 5 mm; beyond this joint congruity could not be restored
after osteotomy. In addition, for the most part it was the
malunions with posterior displacement whose DRU congruity could be restored; those with anterior displacement
were often associated with substantial shortening of the
radius.
Discussion
This study shows that distal resection of the ulna associated
with correction of distal radius malunion does not significantly alter overall wrist function (Mayo Clinic Wrist Score)
or the functional capacity of the upper limb (DASH score)
of the patient satisfaction index. The same holds true for
recuperation of joint mobility, for both supination, whose
limitation was a frequent indication for correction of distal
radius malunion, and flexion/extension, whose results were
comparable between the two groups, and in agreement with
the literature [8—12]. Moreover, other than a logical displacement of the mobility sectors in the direction of the
osteotomy, we observed a significant increase in mobility,
from 20 to 30◦ .
As an absolute value, grip strength was 37% lower in the
DRU— group, whose members had a higher mean age, but
was comparable in relative value expressed as a percentage
of the contralateral side (90%). These results are in agreement with the literature, with values varying between 60
and 80% [10,13—15].
With satisfactory anatomic restoration after osteotomy
comparable in the two groups, resection of the ulna does
not seem to alter the stability of the osteosynthesis, even
when it is limited to pins in the dorsal addition osteotomies.
B. Coulet et al.
The significant reduction in pain in both groups is the
main source of patient satisfaction. Even if the mean pain
score between the two groups did not differ significantly,
this parameter is the main discriminating factor. In the DRU—
group, the pain relief results were clearly less systematic,
27% reported pain in elementary tasks of daily life and only
27% of the patients presented a pain-free wrist versus 70%
after DRU preservation.
This study did not aim to compare the two techniques
but simply to evaluate the impact of ulnar resection. The
DRU— group was made up of cases of failure restoring
radio-ulnar congruence after isolated radial osteotomy, they
presented more severe forms in older and less demanding
patients. This notion induces a bias in favor of this group
in terms of patient satisfaction, the functional result, and
particularly the variables expressed as a percentage of the
contralateral side. This notion should definitely be taken
into consideration in the analysis of the results. Thus, this
study confirms that preservation of the DRU is preferable,
but that a Darrach-type palliative procedure in severe forms
can provide satisfactory results.
In contrast, the fact that the DRU— group comprised
conservative treatment failures allowed us to detail the preoperative factors conditioning the effectiveness of radial
osteotomy in restoring DRU congruity.
The initial shortening of the radius quantified by ulnar
deviation seems to be one of the main advantages. Fig. 5
clearly shows that beyond 5 mm of ulnar deviation, DRU congruity cannot be restored by radial osteotomy alone and that
ulnar surgery is therefore necessary. We also noted that the
small amounts of shortening making conservative treatment
possible were for the most part in cases of malunion with
posterior displacement, with the anterior forms having a less
favorable prognosis. The research on extra-articular malunion correction of the radius [9—12,14,16—22] shows that all
the authors who did not intervene on the DRU had ulnar deviation values in their series less than 5 mm, contrary to those
associating a palliative procedure on the DRU joint or ulnar
shortening, who reported deviance values greater than 5 mm
[8,23]. Yet in the same series, despite satisfactory realignment of the radial epiphysis, only a few millimeters of ulnar
deviation correction with radial osteotomy was observed.
This explains why many authors recommend shortening the
ulna to preserve DRU congruity after osteotomy of the radius
[23].
Residual pain on the ulnar side of the wrist was the main
difference between the two groups, resulting essentially
from instability of the ulnar stump [9,24]. In a series of Darrach procedures associated with osteotomy of the radius,
Bour et al. [13] reported that 71% of wrists remained intermittently painful. On the other hand, when resection of the
ulna was isolated, Hartz et al. [25] as well as Tulipan et al.
[26] reported rates of 9—33%, and more recently Mansat
et al., based on a series of isolated Darrach procedures seen
at more than 6 years of follow-up, did not report these pain
phenomena.
The DRU— group patients in the present study had
substantial ulnar deviation (mean, 10 mm), with radial
osteotomy restoring only very little length, and considerable
resection of the ulna was most often necessary (Figs. 6—9).
Despite stabilization of the ulna, this factor is the main cause
of pain. It should be noted that in our series the patients
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Distal resection of the ulna and radial osteotomies for malunion
485
Figures 6 and 7 Preoperative AP and lateral X-rays of extra-articular malunion of the distal radius. The parameters taken into
consideration are shown: AP image, medial tilt (MT) of the radius and ulnar deviation; lateral image, anterior tilt (AT). This was a
case of radial malunion with posterior displacement with distal radio-ulnar incongruity and ulnar deviation greater than 5 mm.
presenting the most invalidating pain had the highest initial
ulnar deviation values.
When DRU congruity cannot be restored by radial
osteotomy alone, the alternatives to resection of the
ulna are either palliative (Bowers-type hemiresection or a
Sauvé-Kapandji-type procedure) or conservative (shortening
osteotomy and realignment of the ulna).
In terms of mobility and grip strength, for these palliative
procedures the literature review shows results comparable to ours, on the order of 80% of the contralateral side.
Ulnar sliding of the carpus after resection of the ulna
seems insignificant in the posttraumatic context, as we have
observed and as demonstrated by the large series reviewed
at the long-term reported by Mansat et al. [15].
However, pain in the distal stump of the ulna is the essential problem: the more a shortening procedure is necessary,
the more frequently this pain is experienced by the patient.
Comparison of the different techniques in this precise context is not easy because the analysis of pain phenomena has
not been standardized and the series are relatively small.
In a posttraumatic context after an isolated Sauvé-Kapandji
(SK) procedure, Sanders et al. [27], Taleisnik et al. [28],
and Nakamura et al. [29] reported between 30 and 40% of
patients with pain during moderate effort. Despite stabilization of the distal stump of the ulna, using the flexor carpi
ulnaris, Lamey et al. [30] still had 20% painful wrists. Only
Carter et al. [31] reported a series that was comparable
to ours associating four cases undergoing a Sauvé-Kapandji
procedure with osteotomy of the radius: only two cases
improved and 50% of the patients still experienced pain.
The notion of the length of the distal stump of the
ulna is essential. Daecke et al. [32] showed that ulnar
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486
B. Coulet et al.
Figures 8 and 9 Postoperative AP and lateral X-rays after radial osteotomy using a dorsal approach, graft using the ulnar head
and dorsal osteosynthesis with pin fixation.
resection after the Sauvé-Kapandji procedure should not
exceed 35 mm; otherwise, an unstable stump could appear.
In cases of substantial shortening of the radius, the Darrachtype resection makes it possible to limit the height of the
ulnar cut, whereas a Sauvé-Kapandji procedure necessarily
requires cutting the ulna more proximally, a source of instability and pain.
Bowers-type [33] hemiarthroplasty is not an answer to all
problems. The author reports 11% painful stumps, Bain et al.
[34] 32% based on a series of 49 cases, and Watson 27% [24].
Osteotomy shortening the ulna is a logical alternative
to restore DRU congruence. Some authors propose this
osteotomy at the same time as radial osteotomy [23,34,35],
others at a later time [8]. Irrespective of the risk for nonunion, these authors report satisfactory recuperation of
mobility and grip strength 73% of the contralateral side,
comparable to our results. As for pain, in three cases Wada
et al. [23] and El-Karef et al. [8] in six cases, report 33%
persistent pain with certain cases showing substantial loss
of strength. Ulnar realignment osteotomy is effective when
the main deformity of the radius is shortening, but much
less so in cases with a rotational component or incomplete
malunion correction.
In 37 malunions of the distal radius, Prommersberger
et al. [36] showed a rotational component in 27 cases,
with a majority of anterior malunions. This deformity
is rarely taken into account in correcting malunion,
even though it affects restoration of DRU congruity
after osteotomy. Moreover, in cases of ulnar section, it
increases loss of colinearity between the axes of the
two forearm bones, resulting in overhanging of the ulnar
stump.
Author's personal copy
Distal resection of the ulna and radial osteotomies for malunion
Finally, the integrity of the interosseous membrane conditions the stability of the distal extremity of the ulna. This
factor, put forward by Wolfe et al. [37], is in fact difficult
to assess preoperatively but can explain certain unstable
stumps.
[12]
[13]
Conclusion
This study shows that the impact of distal resection of the
ulna associated by necessity with the correction of malunion of the distal radius is limited in terms of mobility and
grip strength. However, it induces more residual pain on the
ulnar side of the wrist, for the most part through instability of the distal stump. We observed that beyond 5 mm of
radius shortening (ulnar variance), radial osteotomy alone
did not suffice to restore DRU congruity. Darrach-type distal resection of the ulna then becomes an option but carries
the risk of residual pain on an unstable stump and should be
reserved for older patients. In younger patients, ulnar shortening and realignment osteotomy should be preferred when
loss of radius height is substantial and the rotational component of distal radius malunion is limited. An SK procedure
could be entertained in cases of substantial cartilaginous
lesions with moderate initial ulnar deviation.
[14]
[15]
[16]
[17]
[18]
[19]
Disclosure of interest
[20]
The authors declare they have no conflicts of interest concerning this article.
[21]
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